Saturday, August 27, 2011

Has Stephen Stahl Gone Off the Deep End? You Decide.

A reader of my blog alerted me to this rambling blog post by Stephen Stahl on his NEI blog. I've pasted his article and my response below--or you can read the whole thing on his site. I’ll be curious to hear your thoughts.

Here is Dr. Stahl’s post, dated August 23 2011:

"Are future psychiatric treatments doomed? Be careful what you ask for...you just might get it."

Nobody likes drug companies these days. Worse than tobacco companies and big oil companies! Supposedly they have ruined CME and have corrupted psychiatric experts as consultants, lecturers and research grant recipients! Drug companies only engage in expensive patent extension gimmickry and offer no true innovations! Let’s criminalize the marketing of psychiatric drugs, levy billions in fines to Pharma, force out their CEOs and even make them and their Pharma collaborators take the “perp walk” on their way to court in chains and orange jumpsuits and in front of the cameras! Get out of our professional societies! Get out of our journals! Get out of our medical centers! Good riddance!!!

Well, if that is what we have been asking for, we are now getting it. Drug companies have already largely pulled out of our meetings, our live CME and our medical centers. Next, the Pharma-scolds want Pharma to stop doing even legally sanctioned FDA activities such as peer-to-peer dinner meetings (many academic faculties now banned by their medical schools from participating), sampling by sales reps (many clinical centers ban reps), and legal freebies (no coffee or bottled water even allowed in Massachusetts let alone a book). If these Pharma nay-sayers and payors had their say, the new “American Textbook of Psychiatry” would be the Physicians Desk Reference with religious adherence to following the label. This in a field where over half of legitimate practice is off label! And this is progress?

Pharma have heard these protests loud and clear and are now pulling out of psychiatric research. Two of the biggest defectors are the two British companies Astra Zeneca and GSK, who have shuttered all their laboratories for mental health research for good, closing facilities all over the world including those the US, UK and Italy and elsewhere. Also, Pfizer bought Pharmacia/Upjohn and closed their CNS research center in Kalamazoo, Michigan; bought Parke Davis and closed their CNS research center in Ann Arbor, Michigan; bought Wyeth and closed their CNS research center in Princeton, NJ; and then for good measure closed their own CNS research center in the UK. Merck closed their CNS research center in the UK where I worked in the 1980s, then bought Organon/Schering Plough and closed their CNS research center in the UK/Scotland for good measure. I could go on and on. This has had a devastating impact especially on the US and the UK. In fact, the UK has gone from a leader in CNS Pharma Research Centers, to having no big Pharma CNS research at all, with thousands of unemployed R and D scientists there and no prospect of CNS therapeutic innovation coming from their shores in the foreseeable future.

Undoubtedly this is to the great delight of the anti-psychiatry community, lights up the antipsychiatry blogs (e.g., Carlat, http://carlatpsychiatry.blogspot.com/ ), who attract the Pharmascolds, scientologists and antimedication crowd who believe either there is no such thing as mental illness, that medication should not be used, or both. Did you know that psychiatric illnesses are pure inventions of Pharma and their experts to treat patients that do not exist with drugs that are dangerous and do not work with the purpose only of profiting themselves? Stop the profits! Make mental illness go away by legislation and committee! Treat human mental suffering with love and peace and all will be well! Who needs mental health professionals and their diabolical drugs anyway?

If you were in the Pharma business, would you work with psychiatry anymore? So, we have gotten what many of us have asked for. No Pharma. But that also means no new drugs. This has sparked a crisis in mental health therapeutic research worldwide but especially in the UK and US. The UK in fact is having a crisis meeting at the Royal Society of Medicine in August, where I am attending with about a dozen others, including the head of the NIMH from the US, the head of the MRC from the UK, and various UK and US academic and industry leaders to discuss what we should do about this. The last time I went to such a meeting was in 1987, where I co-chaired a meeting on this same topic with the famous Paul Janssen (now deceased), the prize winning inventor of Haldol, Risperdal, Fentanyl, Lomotil, and more. At that time I stated that the future could not be more promising (Stahl 1987). What a difference 25 years makes! Returning now to the same Royal Society of Medicine with others, but now with our collective tail between our legs, we are stating that “things could not be worse.” Were the last 25 years of mental health treatments discoveries so worthless as to discard these efforts for the future? Once you stop things, it takes a long time to start it up again. David Nutt, UK psychiatrist extraordinaire and a good friend who will be at the meeting at the RSM, is recently quoted in the UK press as saying, "What we have forgotten, and must not forget, is if we stop this research we will have a dead space of 20 to 30 years before we can re-tool again.”

If we shut down, then we and our patients with depression, schizophrenia and other mental illnesses lose hope for any improvement in their situation in our lifetimes. I still think we can innovate (Stahl 2006), but we need a new model and I will get back to you with suggestions from the Royal Society of Medicine meeting when I return. Some good ideas are coming mostly from Europe as the US is still intent on shutting down Pharma. As a former Lilly president told me recently, “We will someday be a great Chinese drug company.” To reverse this trend and keep this industry in the US, we can try to support innovation through the NIH, and I have volunteered to serve on advisory committees on new drug development if that ever gets off the ground; but this NIH drug development effort is now threatened by the current US budget austerity. We can try to do it though academia, or small companies. The ECNP (European College of Neuropsychopharmacology) of which I am a member has some creative ideas which I strongly support such as trying to persuade drug companies to share the information they already have, putting details of their research and unused potential drug discoveries into a "medicines chest" that outside organizations can exploit, with the ECNP providing insurance against any potential litigation. Medicines for brain disorders take longer to develop than for other conditions - on average, 13 years - and there is a high failure rate. It looks like the UK and the Europeans are much more active in trying to resuscitate mental health therapeutics, while we in the US remain hell bent on destroying what is left of it. We can join the British and the Europeans and move forward, or we can completely kill this industry and wait a decade or two, while experiencing no progress and thus leave a legacy of no innovation and no apparatus to innovate. We will have to see if our children or grandchildren who become mental health professionals want to rebuild a Pharma industry that is interested in mental health or if yet another industry leaves the US for good.

Be careful what you ask for. You might just get it.

Here is my response, dated August 27, 2011:

Dr. Stahl: Your rant is long on rhetoric but short on fact.

Your key argument appears to be that increasing regulations on pharmaceutical marketing techniques have led to the drying up of the CNS pipeline. While you provide no evidence to back up your argument, there are many reasons to question this.

1. Other fields of medicine have seen a boom in new agents--diabetes, oncology, and cardiology are examples. New rules in academic medical centers limiting participation in speaker’s bureaus, access to drug reps, and gifts from drug companies have applied in these fields as well as psychiatry--but appear not to be limiting innovation.

2. In psychiatry, many potentially novel agents have been developed and tested during the "pharma-scold" era but have failed in clinical trials because they have simply not worked, not because medical schools have told their faculty not to accept money to tout them. Examples are numerous, and include Substance P antagonist and mifeprestone for depression, J & J's anti-amyloid bapineuzumab for dementia (along with many other anti-amyloid agents from other companies), and Lilly's anti-glutamate agent mGlu2/3 for schizophrenia.

3. Drug companies have introduced many psychiatric medications over the last two decades, but they have made the business decision to invest heavily in me-too agents, some of which, such as Pristiq and Invega, are embarrassingly blatant patent-extenders with no clear advantages over existing agents. Perhaps if companies had invested more resources into developing truly novel compounds, they wouldn’t be in the pickle they are in.

The reason that some companies are pulling out of CNS drugs is not because of the Carlat Blog (though I’m flattered that you believe I have so much clout) but because the brain is an incredibly complex mechanism and we have yet to work out the basic neurobiology underlying mental illness. As a psychiatrist, I prescribe drugs all the time and I know both their promise and limitations. Far from being “anti-psychiatry,” I would welcome novel drugs to ease my patients’ suffering.

Please show us some evidence for your position. That would be better than more low blow ad hominem attacks on those of us who are trying to improve the pharmaceutical industry by making it more ethical.

Bizarre. How are you anti-psychiatry when one of your main gigs is to write a (very helpful, thank you) psychopharm newsletter? Maybe the truth of the matter is that the psychotropics are hard to prove worthy in an era of stricter research and closer scrutiny.

I've had the feeling that Stahl drank the PhARMA kool-aid for some time now, and his post sounds just like the typical defenses that the paid-off "opinion leaders" use.

Drug companies did not used to be as dishonest as they have been the last few years. I personally am not against pharmaceutical companies spinning their data to emphasize their strenghts and minimize their drawbacks to some degree, nor am I against them sponsoring CME, or even giving out free meals and pens.

What I am against is the blatant and insidiously-disguised dishonesty of their recent marketing strategies, which seem to have become their norm, and which have corrupted academia to an unprecedented degree.

On the other hand, as one who blogs about PhARMA nonsense just like you do, I have indeed had more than my share of comments from the anti-psychiatry types that Stahl describes:

"...the Pharmascolds, scientologists and antimedication crowd who believe either there is no such thing as mental illness, that medication should not be used, or both. Did you know that psychiatric illnesses are pure inventions of Pharma and their experts to treat patients that do not exist with drugs that are dangerous and do not work with the purpose only of profiting themselves? Stop the profits! Make mental illness go away by legislation and committee! Treat human mental suffering with love and peace and all will be well!"

This is a very accurate characterization of the antipsychiatry types.

Of course, since you and I both prescribe psychiatric medications ourselves, we are obviously NOT the people who fit this description. We do, however, sometimes give them a forum in which to speak. But in a free country, that is unavoidable.

Just like the middle ground in American political discourse seems to have evaporated, so has open-minded discussion of psychiatry's problems.

Off the deep end for sure. Stahl misses the point completely: psych treatments aren't doomed -- CORRUPTION is doomed (hopefully), and that can only be a good thing. If you connect the dots, saying psych treatments are doomed because (corrupt!) pharmaceutical companies are withdrawing from the market is actually one hell of a revealing statement.

Yes, pharma largely withdrawing from the market may mean a slowing of new drugs from the pipeline, but that also means far less collateral damage to innocent patients (including patients who shouldn't have even been on this stuff in the first place), and more effective treatments for all.

I see pharma's withdrawal as a wonderful opportunity for psychiatry to do some desperately needed soul-searching and get back to what really matters: REAL SCIENCE. It won't be easy, but nothing worthwhile is.

Sorry to double-dip, but I want to comment on something David Allen said:

David, I agree wholeheartedly with everything you said EXCEPT that you agree with Stahl's quote about the "antipsychiatry crowd":

"Did you know that psychiatric illnesses are pure inventions of Pharma and their experts to treat patients that do not exist with drugs that are dangerous and do not work with the purpose only of profiting themselves?"

Now, I'm just not sold that EVERY disorder in the DSM is valid. What about the Serafem/Premenstrual Dysphoric Disorder debacle? That seems like an iffy disorder cooked up to extend the patent of a drug (Prozac) to me.

And you yourself quoted Allen Francis on your blog when he said "the drug companies learned a while back that the best way to sell drugs was to sell diagnoses… selling the diagnosis is a way of opening up the new market. New diagnoses are as dangerous as new drugs, at least in psychiatry."

You then went on to criticize this "disease mongering," specifically criticizing bipolar spectrum disorder.

Thanks for your comment. Yes, I agree with what you say. As you must know from reading my blog, I think SOME DSM disorders are a complete crock.

What I was talking about in this last post is "the all-or-none thinking anti-psychiatry crowd." They seem to think that if a drug turns out to be ineffective for some symptoms or in some patients, then ALL psychiatric drugs must be ineffective for ALL psychiatric symptoms in ALL patients. They think that if some diagnoses are bogus, then ALL of them must be, etc., etc.

We in the business call this "black or white thinking" or "splitting," and as I said on another blog, it is a serious logical fallacy (as well a symptom of a certain personality disturbance).

Dr. Stahl reported, "The UK in fact is having a crisis meeting at the Royal Society of Medicine in August, where I am attending with about a dozen others, including the head of the NIMH from the US, the head of the MRC from the UK, and various UK and US academic and industry leaders to discuss what we should do about this...."

He promised to report back. This will be an interesting story to follow.

Great response Dr. Carlat. You asked Dr. Stahl, the most important question about where his evidence is.

Dr Allen, you said, "What I was talking about in this last post is "the all-or-none thinking anti-psychiatry crowd." "

I find your comment ironic as in my opinion, many psychiatrists keep patients on meds come heck or high water. There is nothing else in their toolbox. If that isn't black and white thinking, I don't know what is.

I will bet you many of them have never heard of Emily Deans, who I am a big fan of by the way and who has looked into diet approaches for various conditions of mental illness.

The one's getting out are getting out because their biological models and assays map to me-too drug development and that's out of gas with CNS, because of pricing pressure and strongly coupled side effects.

When new ideas surface, Big Pharma will get back in.

The paradox is the huge level of effort being applied to neuro-psychiatric diagnostics like fMRI that have produced limited links to drug development. I.e., the wiz-bang machinery can locate and colorize a psycho-pathology, but so what?

BTW, the psychotropic horse has been out of the barn for years. Like it or not, the normative psychiatric practice model is now the psycho-pharm 15 minute "med check". Faustus Psychiatry has been thoroughly seduced by Mephistophilis Big Pharma. There's really nothing left to corrupt.

The Big Pharma psycho-pharm marketing objective is brand switching of me-too drugs. Those expensive dinners merely move the therapeutic food around the plate.

Once again, you are absolutely right about many psychiatrists and black/white thinking!

It seems I spend half the time I devote to seeing patients trying to get them off inappropriate or no-longer-necessary medications prescribed by previous psychiatrists.

Many patients who have had major depressive episodes, for example, are never even told that they do not usually have to stay on their meds for more than six months. Or that they need to taper them off when they want to stop them to avoid withdrawal(euphemistically, "discontinuation syndrome").

Dr. Allen, I know it may be difficult to hear criticisms of psychiatry when you work so hard for your patients' wellbeing.

Those patients whom you save from inappropriate medication have been injured by doctors not practicing so responsibly, and many more patients out there are seeing those very doctors. (As for antidepressants for 6 months max, how many doctors, even psychiatrists, do you think know that?)

As they say in the ad biz, nothing kills a bad product like good advertising. The problem for psychiatry is that psychiatric drugs are prescribed to far too many people and there are a LOT of dissatisfied customers out there who are not keeping quiet.

Unfortunately, psychiatry is doing a very, very poor job of educating other doctors and promoting practice guidelines that protect patients. Instead, it's engaged in a defensive turf war (cf Dr. Stahl).

The "all or nothing thinking" you're talking about is the spread of deep mistrust toward psychiatry. Good doctors as well as bad are being painted with the same brush because -- really, who can a patient trust?

As for Dr. Stahl, he sounds like he's complaining about pharma gravy train drying up for his own pet projects, to h*ll with patient safety.

When was Stahl at the shallow end?When was he Not selling the idea that we can "scientifically" target a medicine to a patient based on the receptor affinity profiles? A practice that has never really worked.

He has always oversold the utility of receptor research to push some drugs over others, without proper evidence.

It is very unfortunate that anyone should be so invested in any system of belief that they should feel so threatened of the truth.If there was any real merit to the approach biopsychiatry had taken over the last 25 yrs they would not be having a crisis meeting at the Royal Society of Medicine. I hope the punch is spiked with Xanax because they will need it.

The great thing about the scientific method is that paradigms that cannot be supported by empiric research or at least clinical success die. That is exactly what is happening here. If there is real merit to an idea or an approach it will survive regardless of how many meetings the elite have or do not have.

Many in psychiatry are in a panic because the current paradigm they are so invested in is dying and there is nothing they can do about it nor do they have any other cards in their hand.Instead of pretending to be concerned about their pts their concern is obviously for themselves and their world view.

Human beings suffer painful emotions. To accept this fact but repudiate for the most part the current medicalization of such suffering, is to be seen as a denier of psychiatric illness according to the good Dr S. That is just bullshit. Anyone with a brain who was around and observed Paxil's launch and eventual silent death for the TX of Social Anxiety Disorder is aware of the fact that pharmaceutical companies and their Drs do indeed create psychiatric constructs and market it them for the primary purpose of selling drugs. To deny this is no more credible than denying that there is no such thing at all as psychiatric illness.The reason things are so bad is the attempt which has been made to turn EVERYTHING into a psychiatric illness and the dismal results of doing so.If psychiatry and pharmaceutical companies had not been so interested expanding their customer base maybe this would not be happening.

Like it or not this is the approach psychiatry as an institution has chosen to take in concert with their guide book the DSM.Fact is the general public and a lot of Drs are finally wising up and rejecting it. No matter how many meetings that are held or how much hand wringing goes on they will not change this because this is just the way science works thank God. Things that work survive and those that don't die off and are replaced by something else.

Psychitry as we know it is dying. Hopefully what emerges will be an entity that has dramaitcally reduced the number and kinds of constructs it deems worthy of medicalisation and primary pharmaceutical TX.

As a Scientologist (please note the capitalization, guys) and one of those "anti-psychiatry types" whom Dr. Allen believes Stahl characterizes so accurately, I'd just like to say that this whole discussion is wonderfully revealing of the current situation and the broad, diverse culture of the psychiatric profession.

Dr Allen and Altrostata you both hit the nail right in.Between our own misbehavior or lack of proper training we are harming patients and also misinforming. I see so many pts chronically on antidepressants now unable to stop it and still believing that withdrawal is depression. What is going on.Maybe the problem is not pharma alone but ourselves. I have to add non-psychiatrists prescribing also.

If, as a psychiatrist, all I did was prescribe drugs, then yes, I agree with him that the downfall of drug company research might lead to "a decade or two ... of no progress and no innovation."

(BTW, isn't he hinting here that all the wonderful things he's written about the mechanisms and efficacy of psych drugs over the years... are really not that wonderful?)

But psychiatrists actually talk to people, too. Maybe we can use this time to study and develop psychosocial treatments, refine our diagnostic categories, and determine better uses for existing drugs. That would be innovation.

If I were to sum up Dr. Stahl's blog with one of his many copyrighted images, I would choose Green-Face-Man-Looking-Nauseated.

As a recovering Pharma-profiteer, I know how difficult it is to wean off Pharma's-teat. But Dr. S has suckled for so long that even though the milk has soured, he can't stop drinking. He has made millions (yes, millions) off of his schtick...and clever schtick it has been. Promising to move market share, bad-mouthing products from players who wouldn't pony up any coin, and becoming the Stan Lee of psychiatry has created an empire. But it is time for the Emperor to accept that he has no clothes (at least for the next few years)...and not simply fiddle loudly while Psychiatry burns.

I agree with everything you said except I would not be so sanguine that the current paradigm in psychiatry is dying. I only wish. In fact, I see it exploding.

And doctors and drug companies aren't the only ones to blame. A lot of patients are demanding the quick fixes that this approach promises.

I haven't checked out the blog on the Child and Adolescent Bipolar Foundation Website lately, but there used to be a whole lot of family members blogging who identified themselves with multiple psychiatric diagnoses as if it were the perfect introduction to who they are.

Having recently returned to the academic setting, I can say that the current paradigm in psychiatry is still very much alive and well.

Stahl is revered as a semi-deity and his writings are sacrosanct. Moreover, the entire educational infrastructure-- from textbooks to lectures, and from Boards to PRITE to USMLE to shelf exams-- incorporates this dying (exploding?) model.

It's enough to make me feel schizophrenic-- in the lay sense of the word.

With all do respect to the good Drs A and SMD, of course the current model is alive and well in academic psychiatry. What else do they have? I would not go to a prayer meeting at my local church looking for an update on the current status and validity of religious belief in my neighborhood.You have to look outside and academic psychiatry certainly is not a proper litmus test for what is going in in the rest of the world.

I don't think Dr Stahl would be in panic mode if things were status quo. The fact that pharmaceutical companies are leaving psychiatric research in droves is far more important than what is being blogged on the Child and Adolescent Bipolar Foundation Website.Those people were not convinced they all had multiple psychiatric Dx over night so it will take a little time for them to move on.

This is just the start of serious cracks in the foundation of the Church of Psychiatry. As the money leaves and the advertising slows down things will change. It will take time, years. When there is no money to pay Drs for dinners or reps to convince Drs to prescribe we will see how long their attention span is for whatever the psychiatric illness du jour is. I am not talking about the cocoon of academic psychiatry but rather what is going on in primary care or more importantly Oprah.

Do you really think primary care Drs are going to be treating Bipolar Disorder like it is some foot fungus 10 years after they have seen their last Seroquel rep?

Sure they will still be trotting out tired descriptions of depleted monoamines for the depressed or excessive dopamine for the psychotic in resident training programs years from now. If they did not they would likely have nothing to say at all.

That's not what I am talking about. I think American society's love affair with bio-psychiatry is coming to a close. The death of pharma and its shills is just the start. 10 years from now I bet more Valium is being passed out by GP's than SSRI's to the American public.If so that will be testimant to the enduring nature of the current paradigm.Time will tell...

I hope you're right, but ten years is a long time. When bipolar is used as a synonym for moody in a Katy Perry song, and with the popular acceptance of the bio model I see among high school kids, that tells me that we may have a loooooong way to go.

It is also likely that the drug companies are only getting out temporarily because they've beaten neurotransmitters into the ground and there's nothing new on the horizon (and the new me-too's are not different enough). I guess the glutaminergic drugs didn't work.

If academics discover something truly novel, they will again patent it and license it to the drug companies to distribute.

I am a family doc with an extensive psychiatric practice. First I want to say I admire Dr. Stephen Stahl immensely. He has personally taught me more about neuropsychopharmacology than any other person. I send all my "incurable" cases to him or psychiatrists he recommends with excellent results.Having said that, I am almost 70 years old. When I started in practice, research information was relatively primitive, but we docs worked with an "ethical pharmaceutical industry" that had science and patient welfare on the top of their agenda. Over the years they have morphed into corporate marketing machines, whose bottom line is profit. They have used all kinds of covert financial incentives to attract docs to their products, rope in influence leader docs,distorted and ghost written scientific productions, brought less than safe products to market, and grovelled in direct to consumer marketing.Of course, this not all companies and not all products, but who can you trust and when? FDA has levied monstrous fines on especially Pfizer for repeated illegal promotions.Sure docs and medicine would like more funds for their family and for research in these times of cutbacks. But at what price?Of course Stahl is right, we need continued CME and research institutes - especially in the remaining frontier of medical neurosciences - but at what price? Big Pharma's usual modus operandi is far from trust worthy. Good riddance. Let's all work with our professional societies and independent governmental agencies to reestablish the the base for needed research.

Stahl is a perfect example. He's smart and persuasive, and knows far more neuroscience and pharmacology than I could ever dream of knowing. However, I've gotten to the point where, when I read his papers, I'm constantly asking myself, "which product is he promoting here?" (And often, the title, the abstract, and a glance at the disclosures answers this question.)

I hate thinking about the leaders in my field this way, but it's what I've been forced to do.

This is ad hominem argument attacking a few stereotyped straw men to avoid addressing psychiatry's serious critics.

Have you read Irving Kirsch's The Emperor's New Drugs? What is your response to this most extensive meta-analysis of SSRI trials, showing the drugs to be no more effective than placebo, except in very severe depression? What do you say to Kirsch's finding that the drug advantage over placebo was only 1.8 on the Ham D, when NICE sets 3 Ham D points as the minimum for clinical significance? How about the JAMA piece out of Duke that substantially corroborated Kirsch's findings?

What do you say to Joanna Moncreiff's The Myth of the Chemical Cure, documenting the evidence that psych drugs don't correct imbalances, but cause a broad range of abnormal brain function in normal and abnormal subjects?

How do you view Nancy Andreassen's report confirming that neuroleptic exposure does decrease brain mass? What of the rationalization that decreased brain volume can be therapeutic (after psychiatry's decades of insistence that volume loss was one indication of schizophrenia's pathological process)?

What of Grace Jackson's Re-Thinking Psychiatric Drugs, or her Drug Induced Dementia. Dr. Jackson is a psychiatrist who put her money where her mouth is about psychiatric drugs and successfully defended her license when psychiatry came after her hammer and tongs. Her books are chock full of detailed factual argument.

Is Grace Jackson a "scold?" I think she is brilliant and courageous - if you think she's a scold, please read her books and rebut her point for point.

Delivering a scolding of your own is not an effective rebuttal against the many serious critics of psychiatric drugs.

pdwyer: You read a few books about marginal side effects of little importance in numbers, damage, or severity.

Have you read that there are 30,000 suicides a year? These suicides are few compared to heart attacks or cancer. However, they happen to young people and possibly take away more productive years than more common causes of death.

Have you read that paranoid schizophrenics kill 2000 people a year, such as the 30 students and professors at Virginia Tech University?

Have you read that 20% of us will endure a disabling mental illness in our lifetimes? And that half of them will go untreated.

Have you read that medications are tools? Have you read that all tools have side effects? For example, you need to get to Ohio. You could use a tool such as a car. However, cars cause 35,000 horrific deaths by butchering the body while alive.

So let's stop the use of all tools until all their side effects have been ended. That is what the anti-drug extremists are saying. Those misleading, biased authors should walk to Ohio. Roads are tools, and not allowed. Shoes are tools, not allowed. Let them get to Ohio walking barefoot through bear country in the winter. Coats and clothing are tools. Not allowed, until all their side effects have been stopped.

I am from India ,our situation is bit different but ,whatever Dr.Stahl has written is very true.Edison didn't stop trying for new filaments even after many failure.So new drug invention will be there with failures it doesn't mean to stop and control with ridiculous regulation.Within limitation of ethics this can be done but its very obvious to get angry for over-ethics.Its nothing wrong to take freebies from pharma as they are also doing business and we are part of that.If you are getting paid for your expertise nothing wrong as we are not only field in the world like this.On contrary we should thank Dr stahl for raising voice for this injustice.

Edison didn't stop trying, but he also didn't spend $60 billion annually on PR to sell hundreds of billions worth of light bulbs that didn't work. Additionally, he didn't ruthlessly police the field to prevent anyone else from doing their own experiments. That is not an overstatement: psychiatrists risk their licenses for refusing to prescribe psych drugs; psychologists, social workers and other therapists risk their licenses if they don't refer patients and clients for psychiatric evaluations (which almost always result in prescriptions)). Read The Goose that Laid the Golden Egg, by Douglas Bremner, for an example of what drug companies do to those who cross them.

Your casual dismissal of financial conflicts of interest is exactly what is wrong with Pharma and biopsychiatry. How would you feel if your wife, son, daughter, mother or father's care was compromised by financially driven decisions?

You think there's nothing wrong with psychiatrists accepting drug company promotional perks because you are both in business? Pharma may be a lot of things, but they are not stupid. They spend that money on you because it is very very profitable for them. And that kind of profit is incompatible with honest science and true care for patients. You can rationalize but you can't make it honest or right.

Re Edison's failures: he didn't let his failures stop from further experimentation, but he also didn't pretend to the world that his failures were actually successes, and spend $60 billion/year promoting his failures, convincing the public to buy defective or at best mediocre light bulbs. That's closer to what Pharma and biopsychiatry have done.

Re freebies from Pharma being ok because they are doing businees and "we are part of that.": Pharma doesn't hand out freebies to be collegial - they do it because they know the freebies influence how doctors prescribe. They aren't fools - they don't throw billions in promotion around without getting a payoff for their money. Studies show their marketing and freebies do work - and by "work," I don't mean advance science or provide better care to patients. I mean sell more pills and make more money.

Re your claim that there's nothing wrong with the present relationship between Pharma and psychiatrists, because you "aren't the only field in the world like this." Yes, politicians take money from interest groups, investment banks had cozy relationships with sub prime lenders. Is that the standard you want for medicine? I was a prosecutor for 17 years, and I never once saw a defendant successfully justify his/her crimes by "I'm not the only one who does this." I'm sure I don't have to remind you that your profession deals with human misery and human lives. Surely you don't believe "other people do it" is a justification for short changing those you are sworn to serve.

Perhaps Dr. Stahl needs to try treating a severly manic or psychotic patient (outside of a hosptial) with nothing but peace and love. 24/7 until the episode comes to an end. Then perhaps we can get a more reasoned argument out of him.